Financial AgreementLast Name:First Name:Birthdate:Date: 4/19/2024* For my convenience, this office may release my information to my insurance company, and receive payment directly from them. * I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time. * If sent to collections, I agree to pay all related fees and court costs. * Every effort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible. * I agree to pay finance charges of 1.5% per month (18% APR) on any balance 90 days past due. * I will pay a fee for appointments broken without 24 hours notice. * Treatment plans may change, and I will be responsible for the work actually done.I agree to let this office run a credit report. If no, then all fees are due at time of service.YesNo
Signature will be recorded later.